Reactive lymphoid hyperplasia of the liver: a case report and review of literature

Abstract

A case of a 53-year-old female patient with reactive lymphoid hyperplasia (RLH), clinically designated as pseudolymphoma of the liver is described in this article. The patient was admitted to our hospital for further evaluation of hepatic tumors incidentally discovered at another hospital. Various diagnostic methods, including ultrasonography (US), computerized tomography (CT), magnetic resonance imaging (MRI) and hepatic angiography displayed three small lesions in the liver with outstanding findings consistent with hepatocellular carcinoma (HCC). Surgical resection was performed and the three lesions were microscopically diagnosed as RLH of the liver. The lesions comprised a massive infiltration of lymphoid cells with follicles and hyalinized inter-follicular spaces. Immunohistochemical examination revealed that infiltrating lymphocytes had no prominent nuclear atypia and polyclonality. RLH of the liver is a very rare condition and only twelve cases have been reported in the English literature. Majority of the reported cases were middle-aged women and about half of them had some immunologic abnormalities such as autoimmune thyroiditis, Sjogren's syndrome, primary immunodeficiency, primary biliary cirrhosis. Since they are often clinically misdiagnosed as HCC, surgery is the choice of treatment for these patients. Although their pathology resembles malignant lymphoma, the clinical course is completely benign. The authors propose that RLH of the liver can be discriminated from HCC by its clinical features.

Figure 1

CT angiography showing the conspicuously enhanced lesion in segment 7 through the early phase (arrows) (A) and intensified tumor rim enhancement through the delayed phase along with radial enhancement (arrowheads) (B).

Figure 2

MRI displaying a hypointense signal on T1-weighted imaging (arrow) (A), a hyperintense signal on T2-weighted imaging of the lesion (arrow) (B), and enhanced tumor rim in the delayed phase of MRI (arrow) (C).

Figure 3

Macroscopy of tumor in segment 7 demonstrating the lesion as a well-circumscribed, white-yellowish nodule on the cut surface.

Figure 4

Microscopy revealing lesions comprising massive lymphoid cell infiltration with prominent follicles and hyalinized interfollicular spaces at low magnification (HE, X 2.5) (A), interfollicular areas mainly comprising mature lymphocytes with no nuclear atypia (HE, X 50) (B), strands of amorphous hyalinized material accompanying capillaries in interfollicular areas (HE, X 50) (C), and portal areas apart from the nodules with irregular expansion of infiltration of small mature lymphocytes (HE, X 25) (D).

Figure 5

Immunohistochemistry discovering follicles mainly comprising CD20-positive lymphocytes (X 50) (A), and interfollicularly and circumferentially distributed CD3-positive cells compared to follicles (X 50) (B).